Deceased:
Date of Birth
Age:
Sex:
Last Residence of Deceased if Known:
Place of Death: City/Township:
County:
State:
Date of Death:
Time of Death:
AM
PM
Death Caused by Contagious Disease?
Yes
No
Was the decedent treated with radioactive therapy?
Yes
No
Unknown
If yes, specify type & last date of treatment:
Have all surgical implants been removed?
Yes
No
**PLEASE REFER TO REQUIREMENTS ON BACK OF THIS FORM REGARDING IMPLANTS
Will you be purchasing a cremation box? Yes
No (Cost on Price List)
Authority of Authorizing Agent
I (We),
the undersigned, whose address is below, do hereby certify that I am the closest living
next of kin of the decedent and that I am related to the decedent as his/her
or that I otherwise serve (served) in the capacity of
to the decedent, that I have full legal authority and power, according to the laws of
the state of
to execute the authorization form and to arrange for the cremation and disposition of
the cremated remains of the decedent. In addition, I am aware of no objection to this
cremation by any spouse, child, parent or sibling.
Limitation of Liability
I authorize the crematory to reduce the cremains to particles of uniform size and to
carry out one of the dispositions stated below, All non-combustible materials delivered
with the remains will be disposed or recycled by the Crematorium. I hereby agree to
indemnify and keep harmless Rosemount Memorial Park Crematorium and its representatives
for and from all liability due to said authorization, cremation and disposition of the
cremated remains as stated herein.
Final Disposition
After the cremation, has taken place, Rosemount Memorial Park Crematorium will arrange
for the disposition of the cremated remains as follows:
Date of Disposition (IF KNOWN)
Signature of Authorizing Agent(S) **READ THIS DOCUMENT & REQUIREMENTS ON BACK CAREFULLY BEFORE SIGNING
THIS IS A LEGAL DOCUMENT. IT CONTAINS IMPORTANT PROVISIONS CONCERNING CREMATION. CREMATION IS FINAL AND IRREVERSIBLE.
By executing this Cremation Authorization Form, the undersigned warrant that all
statement and representations are true and correct. This Form was Signed by: Next of Kin
at (location)
This
Day of
, 20
Authorizing Agent
at (location)
This
Day of
, 20
Signature of Next of Kin or Authorizing Agent
Tel. No.
EMAIL
Address
Additional Authorizing Agent if necessary
Signature (Additional Authorizing Agent, if any)
Funeral Director's Verification
I certify that the information given on this form is true, to the best of my knowledge
and Rosemount Memorial Park Crematorium's rules and regulation have been followed in
preparing the body for cremation. All pacemaker, prostheses and silicon and radioactive
implants, if any, have been removed. I further certify that the process has been
properly explained to the family.
Address:
Tel. NO:
License No.:
Type of Container:
Contents of Container:
Date Received:
Time Received:
Amount: $
Method of Payment: CREDIT:
CASH
CHECK NO:
Date Paid: Received by:
Receipt for Cremated Remains
Cremated remains picked up by:
Funeral Director
,
Next of Kin
Third Party (authorization needed)
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